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Home My WebLink AboutHARMONY VILLAGE PUD - PRELIMINARY - 65-93C - SUBMITTAL DOCUMENTS - ROUND 1 - Environmental ReportFORM B j ABOVEGROUND STORAGE TANK SYSTEM DATA QUESTIONS AST ID # 8.1 Do you have all appropriate registrations, permits or approvals required by regulatory agencies for this aboveground storage tank AS ? 02 Has this AST ever been "red? B.3 When was tie last tank tightness test by a certified tester performed for this tank? a.) within the Iasi year _ b. within the last 5 years B.4 Is this AST inactive or decommissioned? B.5 This AST contains: a.) gasoline b.) diesel c.) fuel oil d. waste ca B.6 This AST is coast ix ied of: a.) single wag fiberglass b.) steel c.) double wall fiberglass reinforced plastic (FRP) — d.) double wall steel e_) none of the above 8.7 B.10 UOes ttvs AST have secondary containment? Is the holding the holding capacity the cordainmerit at least 110% of the tank cathe containment at least 110% of the tank ca Has this AST ever leaked? Leak detection of this AST is: a.) visually inspected with mont ty monitoring b.) autortc gauging c-) manual gauging d.) is rot oerformed Product distiri1trlion piping for this tank is: a.) single Mall FRP b.) double watt FRP c.) steel d.) coated and caUcdically protected steel e.) cathodicalty protected steel BA2 Do the dispenser pipelines have sectindary containment which drains to this AST? B.13 Product distribution piping for this AST system is: a.) pressurized piping b. suction piping 6.14 Leak detection for product dislAbution piping for this tank is. a.) automatic flow restridor b.) automatic shut off device — c.) continuous alarm system d.) annual foie testing — e.) fine testing every 3 years f. monthly rnondoring- — B.15 Within the Last three (3) years, has distribution piping for this AST ever a.) been repaired b.) been replaced _ c.) failed tightness testing d.) passed tightness testing -- r c Groundwrlur Te h o4cW. [r . All r gM reserved. 001 8 .--._.:.�.n4 _ <- ^•yai. 1. .. '' : (.. - FORMA UNDERGROUND STORAGE TANK SYSTEM DATA QUESTIONS UST ID o A.12 Are there any tank basin observation wells? If yes, tank basin observation wells for this tank are monitored: _ a-) never b.) daily - c-) weekly — d-) monthly — A.13 Product distritution piping for this tank is: a.) single wad FRP— b-) double wall FRP c.) steel d.) coated and cathodicaly protected steel e.) cathodicaffy protected steel — A-14 Do the dispenser pipelines have secondary containment which drains to this UST? A 15 Product dcstribfion piping for this U ST system is: a.) Pressurized Piping b.) suction piping — A-16 teak detection for product distribution piping for this tank is: a.) automatic flow restridor b.) automatic shut off device I mechanical leak detector j( c.) continuous alarm system y' d.) annual fine testing e.) fine testing every 3 years f.) monthly monitoring A.17 Within the last three (3) years, has distribution piping for this UST ever a.) been repaired / b) been replaced— c.) failed tightness testing_— d.) passed tightness testing A-18 Is Stage I vapor recovery required for this UST? ` A.19 Is Stage I vapor installed on this UST? A20 Is Stage II vapor re0ovefy equipnentrequired for this UST7 A21 Is Stage II vapor recovery equipment installed on all dispensers this UST? A.22 Is this UST system in compliance with all applicable requiations? ';1 Gm�rv_•..�•_r TeCino:o�y. roc., All rim lrtz rc.c rcv FORMA UNDERGROUND STORAGE TANK SYSTEM DATA QUESTIONS UST ID tF A.1 This UST contains a.) gasoline b.) diesel _✓ _ C.) fuel oil d.) waste al A-2 The age of this tank is: a) greater than 25 years — b.)15-25 years c.)10-14 years d.) 5-10 years— e.) less than 5 years 7 J` A.3 This tank is constructed of: a.) single Nall fiberglass reinforced plastic (FRP) _ b.) double wall FRP _ c.) steel d.) concrete e.) other (please specify): — A4 This UST is protected from corrosion by. a-) cathodic protection system b.) interior firing c.) interior lining and catho&c protection system d.) coating and cathodic protection system 7� e.) trbergtass reinforced plastic yQtt� A.5 Leak detection for ttus UST is performed by: a.) automatic gauging b.) one of more of grorumdwatertnordonng or -vapor montonng or interstitial monitoring (double Nall tanks) — or monthly inventory control and tank tightness testing or statistical inventory reconciliation ortank pad observation: wells v4-;&Aeensors 3 - A.6 Has this UST ever beenrepaired? 2 - i A.7 This UST y tested: a.) annually b.) every 5 years A.6 When was the Last tank tightness test by a certified tester performed for this tank? a.) within the Last year d /e(li, b-) 5 �- within the last years U G" n o A.9 Has this tank ever failed testing? A 10 If this tank was not certified as tight, a-) were necessary repairs made to ensure tank integrity / b.) was the tank retested �v - c-) was it replaced d.) was it closed in place - A_ 11 Does this tank have any of the following spill and overfill devices: a.) catchment basins b.) automatic shutoff devices, or overfill alarms, or ball float valves _ 9d CrwM..ater Teehno . Inc., ill n,M1 rescewG. ram- m+ 4.1.1 Is this pr9perty currently serAced e e ,water well boated on this pmpeV�'. 4.12 Is wastewater from this property; d , to a sep6c tank and field system located on this property74� 4.1.3 To the best of your knowledge base there ever been wW water or wastewater dscharges on or adjacent to this property other than to a storm water or sanitary sewersystem? 4.1.4 To the best of your knowkidge has ttusproperty.Li%whad a service bay? If yes, a.) Does or did the aufoimo(Ne bayyhav v floor drain? b.) Does or did the floor drain dschatgeto a (1) dry well (2) municipal sanitary sewersystem, (3) on -site septic system (4) storm water system 4.1.5 To the best of your knowledge have there ever been any floor draws or grates on this property into wt i h j hazardous substances or petroleum products(including antifreeze have ever been discha 4.1.6 Is there an oillwater separator at this 4.1.7 Are there any stormwater system piping or catch basins on or passing under this 4.1.8 Is there an industrial wastewater dsdiarge permit for discharging into the municipal sanitary sewer system for J this 4 2 t). i3rtdei roundiStora e:Tank S. temiE melt .:., ;, ...., xes 421 To the hest of your knowledge are all the USTs, greater Um t 000,gallons, at this property registered with the appropriate slate agency7 If there'am no such'USTs a this propertyjanswer 422 To the best of your kriawledge is the current storage system the first itstalled at this 423 To the best of your knowledge have all USTs that have ewer been removed from thiosed s property been d accondin to a icable ve ? If no USTs habeen removed frotn the property, answer 424 How many USTs are in operation atUus property c.) 7-10 - d.) greater ttran 10 Please specify the total number of USTs at this property. For each UST at Mls , ploase complete both sides to FORM A • UST DATA QUESTIONS 433J l�bave. round Sfora sletns . ` Yes CIO 4.31 To the best of your knowledge is the current AST system the first iutalled at ttris location? N 4.32 To the Crest of your knowledge have all AST's that tow ever been rernowd from this property been dosed according to znoricaNe reautati«n? tf no ASTs have been renaed from the property, answer 4.3.3 How many ASTs are in operation at this property? _ a.) 1-3 /J - b.) 4-6 c.) 7-10 d.) greater than 10 PkNase specify the total number of ASTs at this property. For each AST at dds property, p"e complete FORTH B - ASTDA TA QUESTIONS B84 G�� Tech,.o& v. .. n �1= iese ifliy..C• `_ •# U ls,It � lF' eGv3:i y CX'� <a 1�^A'� ^� '.� / v ii��rDCCf�ieaali� ` ..i2t�lt CS� FKi��F h qYn TyrF E? r 3.1.1 � � How often are fuel crventory recoriadatiorls performed on this propettyt; , b) between daily and weeldy -- c.) between weeldy and monthly -- d.) less often than monthly — 3.12 How often are motor fuel storage tanks gauged on this property:. a.) twice daily b.) daily — c.) Only when product shipments are due or arrive — 3.1.3 Is waste oil stored at this 3.1.4 Are spent and/or unspent solvents stored at this properlp 3.1.5 Are current inventory records of fuel receipts/sales kept at: a.) this property b.) a general administrative office — c.) not kept — 3.1.6 When this property driveway, parldng lot, dispenser islands, service bays, etc. are washed, does the runoff of fluids lbw to a: a.) sanitary sewer /storm sewer b.) odhvater separator — c.) street — d.) ground surface — 3.1.7 To the best of your knowledge, have fiquid wastes at this property (e.g. spent solvents, waste ads, waste fire!-.) ever been clischargedto: a.) sanitary sewer / storm sewer b.) orlMater.separator J C.) ground surface 3.1.8 Are YOU aware of any reportable spills or overfills that have occurred.during off-lloading of 9 urg product trio storage tanks at# fs 3.1.9 Are any.of the following wastes generated at this property. a_) freon / antifreeze b.) oily rags c.) used ad filters d.) used batteries e.) used tires f.) waste paint �- g-) used solvents — h.) used sorbent i.) waste oil ✓ 11 _10 Does this property have a dewatering sump for flood prevention? If yes, does the sump discharge to a: a-) sanitary sewer or storm sewer b.) dry well c.) septic system Grw:�pwata TeWWhy, 4�c., Anl rights ms.,,e& "4 It "p--rpperV.'!oqated guar sole source 24.1 Has ttme ever been or do you have any knowiledge of any reportable surface or subsurface spills, overfills or releases of petroleum products or hazardous substances associated with operations at this property? 2.42 Has there ever been or do you have any krw edge of any reportable surface or subsurface spills, overfills or releases of petroleum products or hazardous substances associated with Operations at an adip"rd property? 24.3 To the best oiybur MwMedge, have there ever been cornpla . bits from surrouncring properties within 1500 feet of this property regarding hydrocarbon vapors? 24.4 To the best ofy.mr.knowledge, has Mere ever been. or is there CUMN*Y, or is there planned, a groundwater or $04 6eartup at Nts'Woperty? If Yes. Please enclose copies of all Rernediation Reports within the past ten (10) years. 245 To the best of Your kruNAedoe. has contamination from this nmrA-jtv imnadpd nnv wafer 25.1 Wittiln 15W feet of this property, are you aware of any'. a.) surface water bodies (lakes, rivers, creeks. ponds, etc.) b.) bmuxts, basements or elevator shafts c.) wetlands d.) public of prKrate water supply wells 252 W" 2500 feet of this property, are you aware of any. a-) surface water bodies (takes, risers, creeks. ponds. etc.) b.) tunnels, basements or elevator shafts c.) wetlands - water supply wells d.) public or private w 25.3 Are you aware of any underground utility vaults, conduits, or trenches within 500 feet of this property IGA GTwd.+afa T.Wnbgy, h, . An ngtft rose..ca 21.1 Do you Have all required environmental operating pempts for this property Qe. product/fuel storage, discharge remedial system ? If the is not presently being operated, answer 2.1.2 Has this property ever been used as a waste 21.3 Was there a product storage/dispensing system on this property a.) before 1980 to.) before 19M c.) before 1940 21.4 Are you aware of any release or presence above regulatory reportable quantities at this property from: a.) radon b.) PCBs ✓ c.) asbestos a� d.) pesbcIdes s� e.) herbicides f .) hazardous materials other than pehdeum, Please specify 21.5 Are you aware of any environmental assessment performed on thus property? N�f Know r ff ves. please enclose conies of all assessment reports performed within the oast ten 1101 vears. 221 To the best of your knowledge, do properties within 25W feet of this property primarily consist of, or are zoned as: — a.) residential b.) industrial c.) commercial/retaft _ d.) ruralfundeveloped ✓ — 222 To the best of your knowledge. within 15W feet of this property, have any of the surrounding properties ever been used as a: a.) gasoline station? — b.) dry cleaners? r� c.) photo developing Property? d.) pmkyard or landfill? ^ // ? �� a-) manufadurin9 Plant? /L�/E iL� `Fl -- 23.1 The predominant soil typelsubsurface material in the area of this property is: a.) clay b.) sflt c.) sand d.) bedrock 2.32 Does this property have any groundwater monitor wells on site? If yes, please enclose copies of all assessment reports perfoffned within the past ten 10 ears. 2.3.3 The approidmate depth from ground surface of this property to the upper water bearing stratum (groundwater) is: a.) greater than 50 feet _ b.) 3150 feet c.) 1530 feet _ d.) less than 15 feet 23.4 The approbmate average depth from ground surface of this property to the bedrock is: a.) greater than 50 feet b.) 3150 feet -_ c.) 1530 feet _ d.) less than 15 feet 23.5 Is this property located in the recharge zone of a sole source drinking water aquifer?' A recharge zone is defined as an area where surface water runoff directly lnfitt ates downward into deeper parts of the aquifer. o4 GmuncN a TedvroroW. Lx . Ail righ mtwr , 1.1.1 Property Name: Property Address: Li rY i6at-kfae *-gtYoat f -y Property Phones` City �� i funs V county Larr Nine-r State: l fJ ZIP: Please specify how marry years you have owned and/or operated this property. 1.12 Name of ban applicant Y�elrtr ®t l y� Phase- ry0 T —/ Name of property owner. �.� cal, p vVu'�vu�— Pray Phone: What is the purpose of this ban? Pro uisition Loan c.) Refuancing,-- (Please circle one Pro Can cbon d.) PropelW:Moddication Loan or'no � for which the ban is sought presently a service station? (Circle -yes' Yes' No ' . tda 1.1.3 Is this property recognized by another name for correspondence or permitting purposes? If yes, please specify D i eL t b �� elo J .� Yt I 1.1.4 Does this property have an EPA waste generator number? If yes. Pose specify number 12 0 al iltforittation My " Y ? .. Yes No 121 Have you pleaded -no contest" or been convicted of a f seven ? elary vgtat on of arty envirnnrtnetttal {aw;w" the past 122 Has this or r property �y other properly or businessypo own or operate been Ihes�jeafaij:errvvoninenfa! enforcement action by federal, slate, or local aget>des wtmh has led to a notice'of?violafipniafuderwhich remains unresoNed as of the date of this 7 123 Do you know of any Wasting, threatened. or pending dairrl, Judgment, yen, or tawsu3t5rncetninglhe ruse of hazardous substances or Petroleum Dmduds mvotvinn n ,,r 1.31 Does the state in which thus property is located currently have in place a Leaking Underground Storage Tank trust fund LUST Trust Fund)? own and operate: 1,32 .great than 1000 ST's C;CGf/r�s b.)100-999 UST's _ c.) 13-99 USTs d.) less than 13 USTs ' This includes all your properties 1.3.3 Are you protected against third party environmental liability claims at all currently operating properties using any of the folbwing methods: (answer all that appy) a.) financial test of self-insurance -- — b.) guarantee — C.) indemnity contract �1 d.) insurance �gs•�-� e.) risk retention group coverage f-) surety bond / fetter of credit Please enclose copies of all financial assurance documentation �4m"ffwr T-Nvlogy. Inc. AL rip}" resemd. ,� lP. . ENVIROi11y11MSSl�ENTAL COMPLIANCE QUESTIONNAIRE -Upon completion, check,each" When all items are checked, sign below and mail your questionnaire with this checklist perinstruoo�s ❑ Every question is answered either "yes" or "no'. ❑ "Form A' for each UST and "Form B" for each AST have been completed. ❑ All responseshave been verified with owner/operator, if different from the applicant ❑ Financial assurance documentation has been attached. ❑ Environmental assessment reports within the last ten (10) years, if any have been -performed, have been attached. ❑ Remedation repoifis within the last ten (10) years, if applicable, have been attached. ❑ Questionnaire -Certification has been signed. ❑ Estimated time to zlomplete questionnaire Hrs. Applicant S� Sc�,roflle�t-- (Print' Name) Title Date k ENVIRONMENTAL COMPLIANCE QUESTIONNAIRE